Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38784.384109.2F (Published 27 April 2006) Cite this as: BMJ 2006;332:995
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Dear editor,
This article has been read with great interest. The methodology used
is being greatly appreciated, however I would like to highlight few
points.
1. While comparing the two methods used for auto grafts, more
emphasis is being made on the morbidities caused by patella tendon grafts
(anterior knee pain, loss of extension, impingement and arthrofibrosis)
while the morbidities which can be caused by hamstring grafts have been
left without much mention.
2. The economic aspects of these methods and the difference in
operating times have not been referred to. Forssblad et al [1] has shown
that there is a considerable cost difference between these two.
3. The symptoms of knee pain while squatting and kneeling following
hamstring grafts have been well documented. Goradia et al [2] showed an
incidence of 38% knee pain due to different reasons in their series
following hamstring grafts.
References
1. David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J
Schranz, and Rémy S Nizard. Bone-patellar tendon-bone autografts versus
hamstring autografts for reconstruction of anterior cruciate ligament:
meta-analysis. BMJ 2006; 332: 995-1001.
2. Forssblad M, Valentin A, Engstrom B, Werner S. ACL reconstruction:
patellar tendon versus hamstring grafts-economical aspects. Knee Surg
Sports Traumatol Arthrosc. 2006 Mar 29.
3. Goradia VK, Grana WA, Pearson SE. Factors associated with
decreased muscle strength after anterior cruciate ligament reconstruction
with hamstring tendon grafts. Arthroscopy. 2006 Jan;22(1):80
Competing interests:
None declared
Competing interests: No competing interests
I read with interest the meta-analysis published by David Baiu (1)
and corresponding four Rapid Responses explaining patient's choice and
perspective. Jury still seems to be out on which one is a better fixation.
Proponents for PTB Graft would profess that the graft would integrate
into Bony Tunnel better than Hamstrings graft. I accept that the incidence
of Anterior Knee Pain would be greater with PTB than Hamstrings Graft. In
some societies this may not be acceptable at all, as in Muslim World &
Middle East where patients would have to kneel several times per prayer
and up to five different times of the day for their prayers. This would
surely mean a poor quality of life! It would also be important to know
what would patient prefer, as a professional may have different
expectations from someone who is a keen sportsperson ( either male or
female).
These both surgeries have been around for sometime and yet we have to
wait for a multicentre trial to decide the issue. With the current
advancement of technology and the number of operation performed per year
alone in United States (2) it is a shame that we don’t have a system
whereby all this valuable information being generated can be interpreted.
In the U.S. in 1996, doctors performed ACL repairs on more than 100,000
patients across ambulatory (72,000) and inpatient (35,300) settings.
In the U.S. in 2003, doctors performed 8,900 ACL tears in inpatient care
I would suggest that all surgeons either doing PTB or Hamstrings
should be asked to use a SINGLE VALIDATED FUNCTIONAL SCORING SYTEM /
QUESTIONNAIRE both pre-operative & Post Operatively for every single
surgery as expectations may be different on the basis of gender. In 2003,
the inpatient data shows that 44% of ACL tear repairs were performed on
women and 56% on men.(2) This information perhaps can be collected online
as is currently being done so for NJR ( National Joint Registry on the
same basis as Swedish Hip Register). It is well established that national
register for surgical procedures have benefits. So why not extend them
internationally when this is not so difficult with availability of
internet.
This would allow us to have something similar to multicentre trial.
As the final outcome would be dependant on the skill of the operating
surgeon and which technique they have been using. This could be a good
trade-off to randomization.
The numbers available from North America suggest if similar number of
operations are being carried out in Europe & United Kingdom, it would
be matter of couple of years before we have evidence in front of us!
Perhaps this is the time when international orthopaedic organizations like
SICOT (Société Internationale de Chirurgie Orthopédique et de
Traumatologie) or EFORT (European Federation of National Associations of
Orthopaedics and Traumatology) should rise to the occassion.
(1)David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J
Schranz, and Rémy S Nizard
Bone-patellar tendon-bone auto grafts versus hamstring auto grafts for
reconstruction of anterior cruciate ligament: meta-analysis
BMJ 2006; 332: 995-1001
(2)http://www.aaos.org/wordhtml/research/stats/ACLRepairfacts.htm
accessed on 01 May 2006
Competing interests:
Specialist Registrar Trauma & Orthopaedics performing PTB ACL Reconstructions
Competing interests: No competing interests
Dear Sir,
We would like to thank Dr Mrak for his appropriate comment relating
to our work.
The indication for operation was not the subject of the analysis but,
as points out Dr Mrak, remains vague for some patients and therefore to
some doctors. The prime indication for anterior cruciate ligament
reconstruction is symptomatic instability; the aim of anterior cruciate
ligament reconstruction is to restore functional stability without
compromising other joint function (ie, full range of movement and no
pain). [1] Therefore what holds for a twenty-year old young patient
practising contact sports may not for a thirty-year old patient who is
sedentary and has no complaints regarding his knee (no episode of
instability) and this whether or not the knee is unstable on clinical
examination. Therefore, the indication may sometimes be equivocal and is
best chosen after discussion with the patient. Meniscal injury at MRI scan
may weight for the operation. The reason why indication for reconstruction
is not clear cut is that we lack scientific evidence that it prevents from
late osteoarthritis, and this is the second point we would like to
discuss.
The scientific basis for anterior ligament reconstruction is that
early stabilization reduces the incidence of meniscal pathology, which may
in turn have a protective effect on cartilage damage. However, so far and
to the best of our knowledge, there is evidence that operative treatment
yields better functional results, but there is no evidence that anterior
cruciate ligament reconstruction prevents from late osteoarthritis and
this despite few randomized controlled clinical trials and meta-analysis.
[2-4] Now the reason why we lack sound scientific ground to rely on when
offering someone a reconstruction is due to the difficulty to conduct
surgical randomized controlled clinical trials and this is our third
point. [5]
We appreciate Dr Mrak’s comment that conservative groups should be
included with treatment groups. However, in surgery, as opposed to
pharmacological trials, there is sometimes such an easy and visible
evidence that link the pathology, the treatment and the results that it
proves very difficult ‘no to treat’ the patients. Chalmers said:
“randomize the first patient” but due to learning curve, reluctance of
surgeons for evaluation and the ‘impossible’ state of equipoise necessary
to randomized trials, we don’t and then it’s too late! Nowadays it would
seem almost unethical not to reconstruct a patient who has a symptomatic
unstable knee due to ACL tear.
[1] ACL reconstruction: best practice. Available at:
http://www.boa.ac.uk/PDF%20files/BASK/ACL%20best%20practice.pdf
[2] Sandberg R, Balkfors B, Nilsson B, Westlin N. Operative versus
non-operative treatment of recent injuries to the ligaments of the knee. A
prospective randomized study.
J Bone Joint Surg Am. 1987 Oct;69(8):1120-6.
[3] Andersson C, Odensten M, Good L, Gillquist J. Surgical or non-
surgical treatment of acute rupture of the anterior cruciate ligament. A
randomized study with long-term follow-up.
J Bone Joint Surg Am. 1989 Aug;71(7):965-74.
[4] Hinterwimmer S, Engelschalk M, Sauerland S, Eitel F, Mutschler W.
[Operative or conservative treatment of anterior cruciate ligament
rupture: a systematic review of the literature] Unfallchirurg. 2003
May;106(5):374-9. German.
[5] McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised
trials in surgery: problems and possible solutions.BMJ. 2002 Jun
15;324(7351):1448-51
Competing interests:
None declared
Competing interests: No competing interests
Thank you very much for your fine Meta-analysis.
I would find it also very important to help patients and their doctors in
their decisionmaking on when to operate at all and when to decide for
a conservative approach.
As you point out correctly in your Introduction, the decision about the
technique of surgery is made by the referring practitioner by choosing the
surgeon , but also the decision to operate at all is made additionally
by the surgeon , unfortunately often based on fee for service
objectives, however the outcomes remain controversial, as is clearly
pointed out in your recent Metaanalysis.
I think it would therefore be of great interest to patients and their
doctors , to add an additional controll group of conservatively treated
patients, means without surgery at all , into the evaluation of long
term outcomes of anterior cruciate ligament rupture and its appropriate
treatment. thank you, sincerly Dr. Peter Mrak
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
We would like to thank Dr Purkayastha for his comment on our work. We
feel both perspectives are very interesting.
On the patient’s side, we hope that doctors will give more
information about the outcome and the problems related to both
reconstructions and that hamstring autografts will be shown more interest
from young orthopaedic surgeons.
On the researcher’s side, it is true that meta-analyses are not free of
bias and that one should not consider it as a definite answer. It may help
in summarising the evidence in a clearer way, as was the case for the
morbidity yielded by the two types of reconstruction. It may help in
defining the question more precisely, as was the case for stability
outcomes. And it may certainly help in pointing out the limitation of the
evidence available and the quality of the evidence produced in the
surgical literature. There is a need for improving the quality of
reporting in surgical trials and there is a need for doing multicentre
RCTs to overcome sample size issues. We are currently performing a meta-
analysis based on individual patient data with the help of the principal
investigators of the trials; this should be step forward, but certainly
not the last step to take.
The issue of cost, both financial and quality of life, was not taken
into account as it was never reported in the trials selected; it would
surely be interesting to assess theses issues and may help further in
deciding which graft to choose.
As for the mean follow-up time, it was not from 12 days to 102 days but
from 12 months to 102 months. The authors are sorry for having overlooked
this error in the proofs and that it has misled the reader, although not
quite so: studies that had not a minimum of 12 months follow-up were
excluded from the analysis, because, as noted Dr Purkayastha, patient do
need a certain time to recover from this operation.
Dr David Biau, for the study goup.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
I read the meta-analysis comparing bone-patella-bone and hamstring
tendon autografts for anterior cruciate ligament (ACL) reconstruction by
Biau and colleagues [1] with great interest from two perspectives. Firstly
as a patient who has had a bone patella bone graft for ACL reconstruction
5 years ago and secondly as a clinician with an interest in meta-analysis
and its methodology. As a patient, from my own anecdotal experience of
morbidity following the procedure I agree with the authors’ findings
especially with regards to anterior knee pain, which can still be very
troublesome at times. Interestingly, the authors’ conclusions also stress
the importance of discussing such potential problems preoperatively with
patients, especially those from Asia. Being Indian in origin, I would
further support this statement - there have been many occasions where
sitting cross-legged or kneeling for periods of time has been necessary at
religious or social events which has led to serious discomfort afterwards.
From a clinician and researcher’s point of view, I congratulate the
authors on their sound methodology used in this meta-analysis and on their
findings, especially as there is very little heterogeneity between the
studies. However, although the quality of the studies was assessed and was
found to be poor in general, there is no discussion of publication bias
which may be an important limitation to the interpretation of the results.
Also, I note that the mean follow up of the included studies ranges from
12 to 102 days, the majority being well under 50 days. This also may
potentially limit the inferences that can be made from the findings of
this meta-analysis, as certainly from my own personal experience there was
still considerable rehabilitation, tissue healing and muscle strengthening
needed 4 months after the initial procedure and I am sure that this is the
case for many patients. There was no mention of cost in the article (both
financial and quality of life). I am sure that at present such comparative
data is hard to come by, but the time and effort (of the patient,
practitioners and physiotherapists etc) necessary to achieve a complete
return to normal activities is significant and since the majority of
patients who undergo these procedures are young and active, these are
considerations which I would certainly look into now if I were to undergo
ACL reconstruction now.
Yours sincerely
Mr. Sanjay Purkayastha BSc MBBS MRCS
Clinical Research Fellow
References:
[1] Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS. Bone-patellar
tendon-bone autografts versus hamstring autografts for reconstruction of
anterior cruciate ligament: meta-analysis. BMJ. 2006 Apr 7; doi:
10.1136/bmj.38784.384109.2F (last accessed 16th April 2006)
Competing interests:
None declared
Competing interests: No competing interests
Author's reply
Dear sir,
we would like to thank both Dr Syed and Dr Tomas for their relevant
comments.
It is true that randomised controlled clinical trials may not be well
adapted for surgical evaluation. A multicentre database where all
reconstructions would be recorded may be more adequate. The great amount
of information that would be generated owing to the number of
reconstructions performed each year would probably answer many questions.
However, as noted Dr Syed, there are many difficulties to overcome.
The standardisation of reporting, the willingness to share results, the
extra time and money that would need to be funded... The economic
importance of anterior cruciate ligament reconstruction is not that of
joint replacement and therefore, the solution is unlikely to come from
public health authorities. However, a multicentre online database,
starting with only a few dedicated centres with high volume of
reconstruction, led by an expert society may be an answer.
As for the three points developped by Dr Tomas:
1. The specific morbidity caused by hamstring autografts tendon is
not reported thouroughly in enough studies to allow for a fair comparison.
The muscle torque (hamstring and quadriceps) was unfortunately reported
with too many differences between studies to be agregated. Hamstring
tenderness is not well documented, and we believe it may be less important
than anterior knee pain.
2. The economic aspects of these methods have not been referred to
because we had to limit results and discussion to the materials and it was
not assessed by trialists. However, the increased cost of 300 to 400 euros
reported by Forssblad et al.[1] for hamstring reconstructions should be
balanced by the increased morbidity generated by patellar tendon
reconstruction during the first year and after. It may prove that patellar
reconstructions are less cost-effective in the long term.
3. Hamstring autgraft reconstructed patients may report anterior knee
symptoms (69 of 536 patients, 13%), but still, less than patellar tendon
reconstructed patients (105 of 475 patients, 22%).[2] However, we agree
that it is far from being morbidity free.
References
1. Forssblad M, Valentin A, Engstrom B, Werner S. ACL reconstruction:
patellar tendon versus hamstring grafts-economical aspects. Knee Surg
Sports Traumatol Arthrosc. 2006 Mar 29.
2. David J Biau, Caroline Tournoux, Sandrine Katsahian, Peter J
Schranz, and Rémy S Nizard. Bone-patellar tendon-bone autografts versus
hamstring autografts for reconstruction of anterior cruciate ligament:
meta-analysis. BMJ 2006; 332: 995-1001.
Competing interests:
None declared
Competing interests: No competing interests